Fecal_JJ bacteriotherapy_NN1 for_IF recurrent_JJ Clostridium_NN1 difficile_NN1 infection_NN1 Clostridium_NN1 difficile_NN1 infection_NN1 (_( CDI_MC )_) is_VBZ a_AT1 nosocomial_JJ diarrhea_NN1 that_CST is_VBZ increasing_VVG in_II incidence_NN1 and_CC severity_NN1 ._. 
The_AT spectrum_NN1 of_IO disease_NN1 ranges_VVZ from_II mild_JJ diarrhea_NN1 to_II fulminant_JJ pseudomembranous_JJ colitis_NN1 that_CST is_VBZ associated_VVN with_IW significant_JJ morbidity_NN1 and_CC mortality_NN1 ._. 
Most_DAT cases_NN2 of_IO CDI_MC have_VH0 been_VBN associated_VVN with_IW exposure_NN1 to_II antimicrobial_JJ agents_NN2 ,_, and_CC fluoroquinolones_NN2 ,_, cephalosporins_NN2 and_CC clindamycin_NN1 are_VBR the_AT agents_NN2 that_CST are_VBR associated_VVN with_IW the_AT highest_JJT risk_NN1 ._. 
When_RRQ possible_JJ ,_, the_AT offending_JJ antibiotic_NN1 drug_NN1 should_VM be_VBI discontinued_VVN ,_, and_CC specific_JJ antimicrobial_JJ treatment_NN1 directed_VVN against_II C._NP1 difficile_NN1 should_VM be_VBI instituted_VVN with_IW oral_JJ metronidazole_NN1 or_CC vancomycin_NN1 ._. 
The_AT frequency_NN1 of_IO recurrent_JJ diarrhea_NN1 (_( infection_NN1 relapse_NN1 versus_II reinfection_NN1 )_) ranges_VVZ between_II 5_MC and_CC 35%_NNU ,_, and_CC risk_NN1 factors_NN2 for_IF recurrent_JJ infection_NN1 (_( RCDI_NP1 )_) include_VV0 age_NN1 older_JJR than_CSN 65_MC years_NNT2 ,_, low_JJ serum_NN1 albumin_NN1 concentration_NN1 ,_, recent_JJ abdominal_JJ surgery_NN1 ,_, prolonged_JJ hospitalization_NN1 and_CC stay_VV0 in_II the_AT intensive_JJ care_NN1 unit_NN1 ._. 
RCDI_NP1 is_VBZ generally_RR treated_VVN with_IW an_AT1 additional_JJ course_NN1 of_IO metronidazole_NN1 or_CC vancomycin_NN1 ,_, but_CCB some_DD patients_NN2 develop_VV0 a_AT1 chronic_JJ relapsing_JJ pattern_NN1 of_IO diarrhea_NN1 after_II initial_JJ retreatment_NN1 improvement_NN1 ._. 
Alternative_JJ treatment_NN1 strategies_NN2 for_IF RCDI_NP1 have_VH0 recently_RR been_VBN described_VVN for_IF several_DA2 new_JJ drugs_NN2 ,_, including_II rifaximin_NN1 ,_, nitazoxanide_VV0 ,_, and_CC tolevamer_NN1 ._. 
In_II31 spite_II32 of_II33 these_DD2 developments_NN2 some_DD patients_NN2 continue_VV0 to_TO manifest_VVI relapsing_VVG diarrhea_NN1 after_II completed_JJ treatment_NN1 with_IW novel_JJ drugs_NN2 ._. 
Limited_JJ experience_NN1 in_II northern_JJ Europe_NP1 and_CC the_AT United_NP1 States_NP1 with_IW enteral_JJ instillation_NN1 of_IO stool_NN1 bacterial_JJ flora_NN has_VHZ been_VBN successful_JJ at_II breaking_VVG the_AT relapsing_JJ pattern_NN1 of_IO diarrhea_NN1 ._. 
Recently_RR ,_, Aas_NP2 et_RA21 al_RA22 ._. 
treated_VVN 18_MC patients_NN2 with_IW RCDI_NP1 with_IW stool_NN1 collected_VVN from_II healthy_JJ donors_NN2 ,_, and_CC reported_JJ treatment_NN1 success_NN1 for_IF 15_MC of_IO 16_MC (_( 94%_NNU )_) of_IO their_APPGE evaluable_JJ patients_NN2 ._. 
This_DD1 article_NN1 discusses_VVZ the_AT rationale_NN1 behind_II fecal_JJ bacteriotherapy_NN1 for_IF the_AT treatment_NN1 of_IO RCDI_NP1 ,_, and_CC reviews_VVZ the_AT current_JJ cumulative_JJ experience_NN1 of_IO published_JJ clinical_JJ reports_NN2 in_II the_AT peer-reviewed_JJ literature_NN1 ._. 
Colonization_NN1 resistance_NN1 The_AT indigenous_JJ colon_NN1 bacterial_JJ flora_NN can_VM best_RRT be_VBI understood_VVN as_II a_AT1 complex_JJ interdependent_JJ ecosystem_NN1 that_CST performs_VVZ many_DA2 simultaneous_JJ biological_JJ tasks_NN2 ._. 
Some_DD of_IO these_DD2 tasks_NN2 include_VV0 the_AT degradation_NN1 and_CC digestion_NN1 of_IO food_NN1 substrates_NN2 ,_, stimulation_NN1 of_IO the_AT immune_JJ system_NN1 ,_, and_CC the_AT production_NN1 of_IO vitamins_NN2 ._. 
One_PN1 particularly_RR important_JJ task_NN1 is_VBZ to_TO assist_VVI the_AT host_NN1 in_II the_AT defense_NN1 against_II invasion_NN1 by_II exogenous_JJ bacterial_JJ species_NN ._. 
Indigenous_JJ bacterial_JJ inhabitants_NN2 of_IO the_AT healthy_JJ colon_NN1 can_VM impede_VVI exogenous_JJ bacteria_NN2 from_II establishing_VVG themselves_PPX2 as_II part_NN1 of_IO the_AT residential_JJ flora_NN through_II the_AT production_NN1 of_IO antimicrobial_JJ factors_NN2 ,_, by_II competing_VVG for_IF available_JJ binding_JJ sites_NN2 in_II the_AT epithelial_JJ lining_NN1 of_IO the_AT colon_NN1 ,_, or_CC by_II being_VBG able_JK to_TO utilize_VVI available_JJ nutrients_NN2 and_CC food-sources_NN2 more_RGR efficiently_RR than_CSN the_AT competition_NN1 ._. 
This_DD1 biological_JJ defense_NN1 mechanism_NN1 has_VHZ been_VBN labeled_VVN "_" colonization_NN1 resistance_NN1 "_" and_CC it_PPH1 represents_VVZ a_AT1 primary_JJ line_NN1 of_IO defense_NN1 against_II colonization_NN1 and_CC proliferation_NN1 of_IO opportunistic_JJ pathogenic_JJ bacteria_NN2 ,_, including_II C._NP1 difficile_NN1 ._. 
More_DAR than_CSN 90%_NNU of_IO the_AT fecal_JJ biomass_NN1 consists_VVZ of_IO strict_JJ anaerobic_JJ organisms_NN2 that_CST comprise_VV0 members_NN2 of_IO the_AT genera_NN2 Bacteroides_VVZ ,_, Bifidobacterium_NP1 ,_, Eubacterium_NP1 ,_, Lactobacillus_NP1 ,_, Peptostreptococcus_NP1 ,_, Prevotella_NP1 ,_, Ruminococcus_NP1 and_CC others_NN2 ._. 
However_RR ,_, the_AT numbers_NN2 and_CC species_NN diversity_NN1 of_IO the_AT indigenous_JJ bacterial_JJ flora_NN varies_VVZ with_IW age_NN1 ._. 
Comparative_JJ studies_NN2 of_IO feces_NN2 collected_VVN from_II healthy_JJ subjects_NN2 at_II different_JJ age-ranges_NN2 showed_VVD that_CST the_AT numbers_NN2 and_CC species_NN diversity_NN1 of_IO Bifidobacterium_NP1 decreased_VVD with_IW age_NN1 ,_, whereas_CS the_AT numbers_NN2 and_CC species_NN diversity_NN1 of_IO Bacteroides_NN2 increased_VVN in_II the_AT feces_NN2 of_IO elderly_JJ individuals_NN2 compared_VVN to_II young_JJ adults_NN2 ._. 
Colonization_NN1 resistance_NN1 can_VM prevent_VVI colonization_NN1 and_CC infection_NN1 by_II bacterial_JJ pathogens_NN2 in_II the_AT human_JJ colon_NN1 ,_, unless_CS the_AT integrity_NN1 of_IO the_AT microbiological_JJ barrier_NN1 becomes_VVZ disrupted_JJ ,_, as_CSA may_VM happen_VVI with_IW systemic_JJ antibiotic_NN1 therapy_NN1 ._. 
Examination_NN1 of_IO stool_NN1 from_II elderly_JJ patients_NN2 with_IW CDI_MC demonstrated_VVD markedly_RR reduced_VVN numbers_NN2 and_CC species_NN diversity_NN1 of_IO Bacteroides_NP1 ,_, Prevotella_NP1 and_CC Bifidobacterium_NN1 in_II feces_NN2 when_CS compared_VVN to_II healthy_JJ age_NN1 matched_VVN individuals_NN2 ._. 
Furthermore_RR ,_, repeated_VVD episodes_NN2 of_IO CDI_MC progressively_RR reduced_VVD the_AT phylotype_NN1 richness_NN1 in_II the_AT stool_NN1 of_IO these_DD2 patients_NN2 ._. 
Thus_RR ,_, it_PPH1 has_VHZ been_VBN postulated_VVN that_CST strategies_NN2 that_CST result_VV0 in_II the_AT preservation_NN1 and_CC restoration_NN1 of_IO the_AT microbial_JJ diversity_NN1 could_VM be_VBI used_VVN to_TO resolve_VVI RCDI_NP1 when_CS existing_JJ antibiotic_NN1 treatment_NN1 modalities_NN2 have_VH0 failed_VVN ._. 
This_DD1 principle_NN1 of_IO biotherapy_NN1 has_VHZ long_RR been_VBN used_VVN in_II veterinary_JJ medicine_NN1 for_IF the_AT treatment_NN1 of_IO various_JJ enteric_JJ diseases_NN2 of_IO ruminants_NN2 ._. 
For_REX21 example_REX22 ,_, cud_VV0 transfers_NN2 from_II normal_JJ cows_NN2 can_VM be_VBI used_VVN to_TO resolve_VVI the_AT indigestion_NN1 of_IO anorexic_JJ cows_NN2 ,_, and_CC young_JJ foals_NN2 can_VM resolve_VVI infectious_JJ diarrhea_NN1 by_II ingesting_VVG manure_NN1 from_II healthy_JJ adult_NN1 horses_NN2 (_( transfaunation_NN1 )_) ._. 
Colonization_NN1 resistance_NN1 probably_RR explains_VVZ the_AT lack_NN1 of_IO increased_JJ risk_NN1 of_IO clinical_JJ CDI_MC in_II individuals_NN2 who_PNQS are_VBR symptom-free_JJ excretors_NN2 of_IO C._NP1 difficile_NN1 and_CC prevents_VVZ colonization_NN1 with_IW pathogenic_JJ C._NP1 difficile_JJ strains_NN2 ,_, which_DDQ is_VBZ the_AT basis_NN1 for_IF an_AT1 oral_JJ living_JJ vaccine_NN1 with_IW non-toxigenic_JJ C._NP1 difficile_JJ strains_NN2 ,_, currently_RR in_II early_JJ clinical_JJ trials_NN2 ._. 
Fecal_JJ bacteriotherapy_NN1 Fecal_JJ bacteriotherapy_NN1 refers_VVZ to_II the_AT process_NN1 of_IO instilling_VVG a_AT1 liquid_JJ suspension_NN1 of_IO stool_NN1 from_II a_AT1 healthy_JJ donor_NN1 into_II the_AT gastrointestinal_JJ tract_NN1 ._. 
The_AT stool_NN1 sample_NN1 may_VM be_VBI collected_VVN from_II a_AT1 patient_JJ household_NN1 contact_NN1 or_CC an_AT1 unrelated_JJ donor_NN1 on_II the_AT day_NNT1 of_IO use_NN1 ._. 
Prior_II21 to_II22 collection_NN1 ,_, the_AT sample_NN1 donor_NN1 has_VHZ customarily_RR been_VBN screened_VVN for_IF potentially_RR contagious_JJ infectious_JJ agents_NN2 ._. 
After_CS collection_NN1 ,_, the_AT stool_NN1 sample_NN1 is_VBZ processed_VVN in_II the_AT clinical_JJ laboratory_NN1 into_II a_AT1 liquid_JJ suspension_NN1 ,_, and_CC is_VBZ subsequently_RR instilled_VVN into_II the_AT upper_JJ GI_NN1 tract_NN1 through_II a_AT1 nasoduodenal_JJ catheter_NN1 or_CC into_II the_AT colon_NN1 through_II a_AT1 colonoscope_NN1 or_CC a_AT1 retention_NN1 enema_NN1 catheter_NN1 ._. 
Fecal_JJ enemas_NN2 have_VH0 been_VBN used_VVN as_CSA treatment_NN1 for_IF a_AT1 variety_NN1 of_IO gastrointestinal_JJ diseases_NN2 ,_, including_II inflammatory_JJ bowel_NN1 disease_NN1 ,_, chronic_JJ constipation_NN1 ,_, and_CC pouchitis_NN1 ._. 
A_ZZ1 Medline_NP1 search_NN1 using_VVG the_AT search_NN1 words_NN2 pseudomembranous_JJ enterocolitis_NN1 and_CC C._ZZ1 difficile_JJ associated_JJ diarrhea_NN1 resulted_VVN in_II 13_MC published_JJ reports_NN2 about_II fecal_JJ instillation_NN1 therapy_NN1 for_IF recurrent_JJ episodes_NN2 of_IO CDI_MC ._. 
Eiseman_NN1 and_CC coworkers_NN2 were_VBDR the_AT first_MD investigators_NN2 to_TO report_VVI the_AT successful_JJ use_NN1 of_IO fecal_JJ enemas_NN2 in_II the_AT management_NN1 of_IO four_MC patients_NN2 with_IW pseudomembranous_JJ enterocolitis_NN1 (_( PEC_NP1 )_) ._. 
Three_MC of_IO their_APPGE patients_NN2 had_VHD recently_RR undergone_VVN major_JJ abdominal_JJ surgery_NN1 and_CC almost_RR died_VVD before_II the_AT fecal_JJ enemas_NN2 were_VBDR employed_VVN ._. 
More_DAR than_CSN 20_MC years_NNT2 later_RRR Bowden_NP1 et_RA21 al_RA22 ._. 
successfully_RR resolved_VVN PEC_NN1 in_II 13_MC of_IO 16_MC surgical_JJ patients_NN2 (_( 81%_NNU )_) by_II administering_VVG stool_NN1 collected_VVN from_II in-house_JJ family_NN1 members_NN2 or_CC healthy_JJ medical_JJ students_NN2 or_CC hospital_NN1 residents_NN2 ._. 
Two_MC of_IO the_AT 16_MC patients_NN2 received_VVD their_APPGE fecal_JJ instillation_NN1 via_II an_AT1 infusion_NN1 catheter_NN1 with_IW tip_NN1 placement_NN1 in_II the_AT proximal_JJ jejunum_NN1 ;_; the_AT rest_NN1 of_IO the_AT patients_NN2 were_VBDR given_VVN fecal_JJ enemas_NN2 ._. 
Three_MC (_( 19%_NNU )_) of_IO the_AT patients_NN2 died_VVD ,_, but_CCB two_MC of_IO these_DD2 patients_NN2 died_VVD of_IO unrelated_JJ illnesses_NN2 ._. 
Tvede_VV0 and_CC Rask-Madsen_NP1 successfully_RR treated_VVN 6_MC patients_NN2 with_IW RCDI_NP1 in_II 1989_MC ._. 
One_MC1 patient_NN1 received_VVD stool_NN1 collected_VVN from_II two_MC separate_JJ family_NN1 members_NN2 ;_; the_AT remaining_JJ 5_MC patients_NN2 were_VBDR treated_VVN by_II rectal_JJ instillation_NN1 of_IO a_AT1 mixture_NN1 of_IO ten_MC different_JJ facultative_JJ aerobic_JJ and_CC anaerobic_JJ bacterial_JJ species_NN diluted_VVN in_II sterile_JJ saline_JJ ,_, and_CC included_VVN Streptococcus_NP1 (_( Enterococcus_NP1 )_) faecalis_NN1 ,_, Clostridium_NP1 innocuum_NN1 ,_, C._NP1 ramnosum_NN1 ,_, C._NP1 bifermentans_NN2 ,_, Bacteroides_NP1 ovatus_NN1 ,_, B._NP1 vulgatus_NN1 ,_, B._NP1 thetaiotaomicrom_NN1 ,_, Escherichia_NP1 coli_NN2 (_( two_MC separate_JJ strains_NN2 )_) ,_, and_CC Peptostreptococcus_NP1 productus_NN1 ._. 
The_AT bacterial_JJ suspension_NN1 employed_VVN by_II Tvede_NP1 et_RA21 al_RA22 has_VHZ sometimes_RT been_VBN referred_VVN to_II as_RG synthetic_JJ stool_NN1 ._. 
Instillation_NN1 of_IO donor_NN1 stool_NN1 to_II patients_NN2 with_IW RCDI_NP1 ._. 
Once_CS the_AT individual_NN1 who_PNQS will_VM serve_VVI as_II stool_NN1 donor_NN1 has_VHZ been_VBN adequately_RR prescreened_VVN ,_, the_AT actual_JJ instillation_NN1 procedure_NN1 can_VM be_VBI scheduled_VVN in_II an_AT1 expeditious_JJ manner_NN1 ._. 
The_AT patient_NN1 and_CC the_AT treatment_NN1 team_NN1 together_RL must_VM decide_VVI on_II the_AT route_NN1 of_IO administering_VVG the_AT stool_NN1 sample_NN1 and_CC the_AT physical_JJ location_NN1 where_CS the_AT stool_NN1 instillation_NN1 procedure_NN1 will_VM take_VVI place_NN1 ,_, which_DDQ frequently_RR may_VM be_VBI performed_VVN as_II an_AT1 outpatient_NN1 procedure_NN1 ._. 
Furthermore_RR ,_, in_II the_AT days_NNT2 leading_VVG up_II21 to_II22 the_AT instillation_NN1 procedure_NN1 the_AT recipient_NN1 gastrointestinal_JJ tract_NN1 should_VM be_VBI optimally_RR prepared_VVN for_IF acceptance_NN1 of_IO the_AT donated_JJ stool_NN1 sample_NN1 ._. 
The_AT planning_NN1 of_IO the_AT actual_JJ instillation_NN1 procedure_NN1 typically_RR requires_VVZ scheduling_NN1 and_CC coordination_NN1 between_II the_AT operator_NN1 of_IO the_AT instillation_NN1 procedure_NN1 ,_, the_AT clinical_JJ laboratory_NN1 (_( typically_RR the_AT microbiology_NN1 laboratory_NN1 )_) and_CC the_AT radiology_NN1 department_NN1 at_II the_AT treating_VVG facility_NN1 ._. 
Route_NN1 of_IO administration_NN1 of_IO donor_NN1 stool_NN1 to_II recipient_NN1 ._. 
Instillation_NN1 of_IO donor_NN1 feces_NN2 can_VM be_VBI accomplished_VVN from_II either_RR the_AT proximal_JJ or_CC the_AT distal_JJ end_NN1 of_IO the_AT gastrointestinal_JJ tract_NN1 ._. 
Most_DAT reported_JJ cases_NN2 (_( 76%_NNU of_IO the_AT cases_NN2 reported_VVN in_II Table_NN1 1_MC1 )_) received_VVD their_APPGE fecal_JJ infusion_NN1 through_II the_AT rectum_NN1 in_II the_AT form_NN1 of_IO an_AT1 enema_NN1 ._. 
Arguments_NN2 for_IF instilling_VVG the_AT stool_NN1 sample_NN1 through_II the_AT upper_JJ GI_NN1 tract_NN1 include_VV0 ease_NN1 of_IO patient_JJ preparation_NN1 (_( placement_NN1 of_IO a_AT1 nasoduodenal_JJ or_CC nasojejunal_JJ tube_NN1 )_) ,_, ease_NN1 of_IO preparation_NN1 of_IO stool_NN1 sample_NN1 (_( only_RR a_AT1 single_JJ fecal_JJ specimen_NN1 of_IO limited_JJ volume_NN1 is_VBZ usually_RR needed_VVN )_) ,_, a_AT1 relatively_RR low_JJ risk_NN1 of_IO complications_NN2 associated_VVN with_IW the_AT upper_JJ instillation_NN1 procedure_NN1 (_( perforation_NN1 of_IO the_AT upper_JJ GI_NN1 tract_NN1 by_II the_AT NG_NP1 tube_NN1 ,_, and_CC potential_JJ aspiration_NN1 of_IO fecal_JJ material_NN1 are_VBR both_RR theoretical_JJ complications_NN2 )_) ,_, and_CC limited_JJ cost_NN1 for_IF the_AT radiology_NN1 services_NN2 (_( to_TO verify_VVI that_CST the_AT tip_NN1 of_IO the_AT infusion_NN1 catheter_NN1 is_VBZ in_II the_AT correct_JJ position_NN1 )_) ._. 
In_II contrast_NN1 ,_, even_CS21 though_CS22 most_DAT reported_JJ patients_NN2 have_VH0 received_VVN their_APPGE stool_NN1 instillation_NN1 through_II the_AT rectum_NN1 ,_, this_DD1 approach_NN1 is_VBZ inherently_RR associated_VVN with_IW increased_JJ risk_NN1 of_IO complications_NN2 (_( colon_NN1 perforation_NN1 )_) as_II a_AT1 result_NN1 of_IO instrumentation_NN1 of_IO an_AT1 inflamed_JJ colon_NN1 ._. 
Furthermore_RR ,_, lower_JJR tract_NN1 instillation_NN1 requires_VVZ a_AT1 far_RG larger_JJR volume_NN1 of_IO prepared_JJ stool_NN1 ,_, is_VBZ associated_VVN with_IW significant_JJ spillage_NN1 of_IO stool_NN1 leaking_VVG backwards_RL through_II the_AT rectum_NN1 after_II instillation_NN1 ,_, and_CC frequently_RR requires_VVZ multiple_JJ instillations_NN2 distributed_VVN over_II multiple_JJ days_NNT2 to_TO achieve_VVI success_NN1 ._. 
Thus_RR ,_, it_PPH1 is_VBZ likely_JJ that_CST the_AT total_JJ cost_NN1 of_IO the_AT instillation_NN1 procedure_NN1 is_VBZ higher_JJR when_CS the_AT instillation_NN1 is_VBZ delivered_VVN through_II the_AT lower_JJR GI_NN1 tract_NN1 ._. 
The_AT finished_JJ stool_NN1 slurry_NN1 can_VM then_RT be_VBI used_VVN immediately_RR ,_, or_CC frozen_JJ as_CSA multiple_JJ aliquots_NN2 stock_NN1 samples_NN2 at_II -20&deg;C_FO for_IF later_JJR use_NN1 when_CS stool_NN1 has_VHZ been_VBN collected_VVN from_II a_AT1 healthy_JJ single_JJ anonymous_JJ donor_NN1 ._. 
Instillation_NN1 of_IO donor_NN1 stool_NN1 ._. 
As_CSA shown_VVN in_II Table_NN1 3_MC ,_, the_AT volume_NN1 of_IO stool_NN1 to_TO be_VBI instilled_VVN and_CC the_AT number_NN1 of_IO instillations_NN2 needed_VVN vary_VV0 with_IW the_AT route_NN1 of_IO administration_NN1 ._. 
Stored_JJ samples_NN2 of_IO frozen_JJ stool_NN1 aliquots_NN2 should_VM be_VBI thawed_VVN in_II their_APPGE original_JJ storage_NN1 vessel_NN1 in_II a_AT1 waterbath_NN1 prior_II21 to_II22 instillation_NN1 ._. 
A_AT1 nasogastric_JJ or_CC nasojejunal_JJ catheter_NN1 should_VM be_VBI placed_VVN into_II the_AT upper_JJ GI_NN1 tract_NN1 just_RR prior_II21 to_II22 the_AT instillation_NN1 procedure_NN1 ,_, and_CC catheter_JJR tip_NN1 position_NN1 should_VM be_VBI verified_VVN by_II X-ray_NN1 radiography_NN1 ._. 
A_AT1 single_JJ instillation_NN1 is_VBZ typically_RR all_DB that_DD1 is_VBZ needed_VVN when_CS stool_NN1 is_VBZ delivered_VVN through_II the_AT upper_JJ GI_NN1 tract_NN1 ,_, which_DDQ makes_VVZ this_DD1 approach_NN1 expedient_NN1 and_CC convenient_JJ for_IF the_AT patient_NN1 ._. 
Thirteen_MC of_IO 18_MC patients_NN2 (_( 72%_NNU )_) described_VVD by_II Aas_NP2 were_VBDR treated_VVN in_II the_AT ambulatory_JJ setting_NN1 and_CC discharged_VVN in_II the_AT afternoon_NNT1 of_IO their_APPGE procedure_NN1 ._. 
Typically_RR these_DD2 patients_NN2 responded_VVD quickly_RR to_II a_AT1 single_JJ stool_NN1 instillation_NN1 and_CC reported_VVD rapid_JJ resolution_NN1 of_IO abdominal_JJ pain_NN1 ,_, normalization_NN1 of_IO stool_NN1 frequency_NN1 and_CC consistency_NN1 ,_, and_CC an_AT1 increased_JJ sense_NN1 of_IO well-being_NN1 within_II 24-48_MCMC h_ZZ1 ._. 
In_II contrast_NN1 ,_, multiple_JJ instillations_NN2 are_VBR frequently_RR needed_VVN before_II the_AT patient_NN1 develops_VVZ a_AT1 normal_JJ bowel_NN1 pattern_NN1 when_CS the_AT rectal_JJ route_NN1 is_VBZ used_VVN for_IF stool_NN1 instillation_NN1 ._. 
Thus_RR ,_, repeated_VVD instillations_NN2 are_VBR usually_RR necessary_JJ and_CC have_VH0 often_RR been_VBN conducted_VVN over_II a_AT1 period_NN1 of_IO 3-5_MCMC days_NNT2 ,_, which_DDQ may_VM result_VVI in_II increased_JJ cost_NN1 and_CC loss_NN1 of_IO patient_JJ work_NN1 productivity_NN1 ._. 
Typically_RR there_EX is_VBZ a_AT1 significant_JJ back_NN1 leakage_NN1 of_IO fecal_JJ material_NN1 around_II the_AT enema_NN1 catheter_NN1 which_DDQ creates_VVZ a_AT1 bit_NN1 of_IO a_AT1 mess_NN1 and_CC may_VM be_VBI unappealing_VVG to_II the_AT patient_NN1 ._. 
Success_NN1 of_IO fecal_JJ bacteriotherapy_NN1 for_IF RCDI_NP1 The_AT published_JJ experience_NN1 with_IW fecal_JJ bacteriotherapy_NN1 is_VBZ still_RR limited_VVN ._. 
However_RR ,_, with_IW the_AT increasing_JJ frequency_NN1 and_CC severity_NN1 of_IO CDI_MC observed_VVD in_II the_AT western_JJ world_NN1 combined_VVN with_IW a_AT1 lack_NN1 of_IO highly_RR effective_JJ treatment_NN1 options_NN2 for_IF RCDI_NP1 ,_, this_DD1 alternative_JJ form_NN1 of_IO treatment_NN1 will_VM likely_RR increase_VVI in_II acceptance_NN1 among_II patient_NN1 and_CC their_APPGE caregivers_NN2 ._. 
The_AT principal_JJ potential_JJ risk_NN1 associated_VVN with_IW fecal_JJ bacteriotherapy_NN1 is_VBZ transmission_NN1 of_IO contagious_JJ agents_NN2 contained_VVN in_II the_AT donor_NN1 stool_NN1 ,_, which_DDQ argues_VVZ for_IF careful_JJ screening_NN1 of_IO the_AT donor_NN1 for_IF presence_NN1 of_IO occult_NN1 infections_NN2 prior_II21 to_II22 the_AT stool_NN1 transfer_NN1 process_NN1 ._. 
However_RR ,_, no_AT infectious_JJ complications_NN2 or_CC physical_JJ adverse_JJ effects_NN2 from_II fecal_JJ biotherapy_NN1 have_VH0 so_RG far_RR been_VBN reported_VVN in_II the_AT literature_NN1 ._. 
Furthermore_RR ,_, the_AT published_JJ treatment_NN1 success-rates_NN2 have_VH0 varied_VVN between_II 81_MC and_CC 100%_NNU ._. 
In_II fact_NN1 ,_, 89%_NNU of_IO the_AT patients_NN2 shown_VVN in_II Table_NN1 1_MC1 successfully_RR resolved_VVD their_APPGE RCDI_NP1 with_IW fecal_JJ biotherapy_NN1 ,_, all_RR having_VHG failed_VVN repeated_JJ prior_JJ treatment_NN1 attempts_NN2 with_IW standard_JJ antimicrobial_JJ therapy_NN1 ._. 
There_EX was_VBDZ no_AT apparent_JJ difference_NN1 in_II treatment_NN1 success-rates_NN2 between_II patients_NN2 who_PNQS received_VVD fecal_JJ biotherapy_NN1 administered_VVN via_II the_AT upper_JJ or_CC lower_JJR gastrointestinal_JJ tract_NN1 ,_, respectively_RR ._. 
Fecal_JJ biotherapy_NN1 therefore_RR appears_VVZ to_TO be_VBI both_RR effective_JJ and_CC safe_JJ ._. 
There_EX is_VBZ currently_RR no_AT consensus_NN1 on_II treatment_NN1 recommendations_NN2 for_IF patients_NN2 who_PNQS fail_VV0 to_TO respond_VVI to_II fecal_JJ instillation_NN1 therapy_NN1 ._. 
Remaining_JJ questions_NN2 Most_DAT researchers_NN2 agree_VV0 that_CST the_AT fundamental_JJ problem_NN1 with_IW RCDI_NP1 results_NN2 from_II the_AT absence_NN1 of_IO healthy_JJ bacteria_NN2 in_II the_AT colon_NN1 to_TO keep_VVI growth_NN1 of_IO C._NP1 difficile_NN1 suppressed_VVD ,_, rather_II21 than_II22 the_AT presence_NN1 of_IO the_AT pathogen_NN1 per_RR21 se_RR22 ._. 
However_RR ,_, the_AT relative_JJ roles_NN2 played_VVN and_CC the_AT identities_NN2 of_IO individual_JJ bacterial_JJ species_NN (_( especially_RR Bacteroides_VVZ and_CC Prevotella_NP1 )_) that_CST effectively_RR maintain_VV0 colonization_NN1 resistance_NN1 are_VBR currently_RR unknown_JJ ._. 
Future_JJ identification_NN1 of_IO specific_JJ key_JJ bacteria_NN2 that_CST are_VBR most_RGT important_JJ for_IF upholding_VVG balance_NN1 in_II the_AT colon_NN1 may_VM permit_VVI the_AT development_NN1 of_IO commercial_JJ ,_, storable_JJ "_" synthetic_JJ stool_NN1 "_" products_NN2 that_CST will_VM resolve_VVI many_DA2 of_IO the_AT practical_JJ and_CC perceived_VVD esthetic_JJ problems_NN2 that_CST are_VBR associated_VVN with_IW fecal_JJ bacteriotherapy_NN1 today_RT ._. 
